The advocacy nonprofit organization Consumer Watchdog is calling for government officials to audit ten California hospitals recently fined for errors that placed their patients in “immediate jeopardy” of serious injury or death, including John F. Kennedy Memorial Hospital.
The California Department of Public Health last week penalized the Indio hospital for the way it handled a 2011 discharge and transfer of a patient seriously ill with liver disease. The patient later died. Carrying a $100,000 administrative fee price tag, the violation is JFK’s sixth in five years.
Consumer Watchdog, which keeps a close eye on health issues in California, said the state agency fines are not enough to pressure hospitals to improve safety.
“An audit would uncover whether hospitals are honestly reporting when adverse events occur, and reveal what, if any, steps hospitals have taken to prevent these ‘never events’ from happening,” the advocacy group said in a statement.
JFK was one of ten hospitals to receive the “Immediate Jeopardy” penalties last week. Totaling $700,000, the department said each hospital “failed to ensure the health and safety of a patient when it did not follow policies and procedures regarding the treatment and care of a patient.”
Loma Linda University Medical Center is also among the hospitals fined.
“Patients are falling victim to dangerous conditions and preventable medical errors, and California’s elected officials and regulatory agencies haven’t stepped up to fix the problem,” said Michael Kapp with Consumer Watchdog. “Hospitals cannot be trusted to police themselves, and these fines are more evidence that an immediate audit is needed.”
JFK CEO Gary Honts responded to the violation — not the request for an audit — in a statement, saying the hospital has “resolved to the satisfaction of CDPH (California Department of Public Health )” the problem that stems back to something that happened three years ago.
“There is a renewed culture of accountability at JFK, based upon higher expectations for performance and high-quality, patient-centered care,” he said. “We are relentlessly focused on improving the patient experience as a trusted community provider.”
Records from Public Health show the woman, admitted to JFK in 2011 with jaundice associated with liver failure, became critically ill, weak, nauseous and swollen while there. Uninsured, unable to qualify for Medi-Cal and in need of further specialized care, the hospital decided to try to transfer her to a tertiary care center at Riverside County Regional Medical Center.
But after faxing a referral and being told the hospital was closed to outside transfers, the medical team told the patient and her family to drive her to the county hospital emergency room, the statement of deficiencies said. Her son drove her part of the 82-mile journey, but their car broke down on the way, requiring a 911 call and ambulance ride. After being taken to the emergency room and given a poor prognosis, life support was withdrawn.
“Based on interview and record review, the facility failed to ensure a patient was discharged for the purpose of effecting a transfer to another facility without first making advanced arrangements with that receiving facility,” a public health statement of deficiencies states.
The process placed her “at risk for increased health deterioration, harm and death,” it states.
JFK completed a mandatory plan of correction after the error happened, including education, increased monitoring and updating its discharge policies.
The hospital has been fined by the state five times since 2010. Past errors included performing the wrong surgery and an ill-prepared emergency room nursing staff making mistakes.
These fines might not represent all the quality and safety mistakes that happen in hospitals, the watchdog group warns.